IPSS Questionnaire for Prostate Embolization

Patient Name:

Date of Birth:

Email:

1. Incomplete Emptying: (still feeling urine in the bladder after urinating)
Not at allLess than 1 time in 5Less than half the timeAbout half the timeMore than half the timeAlmost always

2. Frequency:(going more than once every 2 hours)
Not at allLess than 1 time in 5Less than half the timeAbout half the timeMore than half the timeAlmost always

3. Intermittency:(stop start urine stream)
Not at allLess than 1 time in 5Less than half the timeAbout half the timeMore than half the timeAlmost always

4. Urgency:
Not at allLess than 1 time in 5Less than half the timeAbout half the timeMore than half the timeAlmost always

5. Weak Stream:
Not at allLess than 1 time in 5Less than half the timeAbout half the timeMore than half the timeAlmost always

6. Straining:(needing to strain to urinate)
Not at allLess than 1 time in 5Less than half the timeAbout half the timeMore than half the timeAlmost always

7. Nocturia:(How many wake ups to urinate on an average night?)
NoneOnceTwiceThree timesFour timesFive or more times

Quality of Life due to Urinary Symptoms:(How do you feel currently?)
DelightedPleasedMostly satisfiedMixedMostly unhappyUnhappyTerrible

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